Cox’s Conference: Chronic Pericarditis

In today’s Cox’s Conference, Dr. Karl Gordon Patti presented a case of chronic effusive pericarditis to expert discussant, Dr. Justin Grodin.

The patient is an otherwise healthy 28 year old black man with a history of recurrent pericarditis. Over the course of 7 years, he had 2-3 episodes of pericarditis per year. Despite prolonged treatment with NSAIDs and colchicine, his flares recurred. He ultimately was placed on a prolonged steroid taper with multiple attempts to wean to no avail. He was trialed on steroid-sparing agents with methotrexate and azathioprine. The former was discontinued due to lack of clinical improvement and reproductive considerations. The latter was discontinued due to drug-induced pancreatitis.

Discussion:

The natural history of, approach to, prognostication of, and management of pericarditis is excellently reviewed in Paul Cremer’s review in the Journal of the American College of Cardiology (J Am Coll Cardiol. 2016 Nov 29;68(21):2311-2328), as suggested by Dr. Grodin. Below are selected pearls from conference and this review.

Diagnosis

The diagnosis of pericarditis is clinical. It is characterized precordial chest pain that is positional (worse when supine) and pleuritic. On physical exam, there can be a pericardial rub best heard with physical maneuvers that approximate the heart close to the chest wall (e.g. left lateral decubitus or leaning forward). Electrocardiographic findings include diffuse ST-segment elevation and PR depression; however, regional ST elevations can occur in settings in which the pericardial inflammation is local due to procedures such as atrial fibrillation ablation and cardiac surgery. Supportive findings include elevated inflammatory biomarkers and pericardial enhancement on cardiac MRI.

pericarditis ekg
Note ST elevations in I, II, III, and AVF with associated PR depressions. https://lifeinthefastlane.com/ecg-library/basics/pericarditis/
Clinical Course

Acute pericarditis can have several sequelae, including recurrence, constriction, myocarditis, and pericardial effusion with tamponade.

pericarditis sequelae
J Am Coll Cardiol. 2016 Nov 29;68(21):2311-2328

As shown above, a majority of patients will have good long-term outcome but a significant minority do go on to develop more severe, complicated consequences including chronic pericarditis, recurrent pericarditis, and chronic constriction. There are several risks that have been shown to be associated with increased risk of complicated disease, the greatest of which being use of corticosteroids.

risks for complicated pericarditis
J Am Coll Cardiol. 2016 Nov 29;68(21):2311-2328
Management

The treatment for acute pericarditis consists of NSAIDs and colchicine. Echocardiogram should be obtained to assess for pericardial effusion, early tamponade physiology, suggestion of constrictive physiology, and wall motion abnormalities (indicating possible recent myocardial infarction or inflammation). This will assist in triage and risk stratification. The table below summarizes the treatment and imaging considerations for various stages of pericarditis from acute to more complicated stages.

treatment
J Am Coll Cardiol. 2016 Nov 29;68(21):2311-2328